CurrentHighmark Blueshield NenyPolicy N/A

Certificate of Medical Necessity for Osteogenic Stimulators

Form and clinical checklist governing documentation required to request ultrasonic or electrical osteogenic stimulators (spinal and non-spinal) for fracture nonunion, failed fusion, or related indications; intended for providers submitting CMNs to the payer.

Policy Summary

PayerHighmark Blueshield Neny

PolicyCertificate of Medical Necessity for Osteogenic Stimulators

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the device-specific CMN section and include a typed office note with clinical dates, radiographic evidence, and prior treatment details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3device categories

Office noterequired supporting doc

ChecklistCMN format

Coverage Criteria and Medical Necessity

Device-specific CMN criteria

Covered when the completed CMN documents the following, as applicable to device type:

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Ultrasonic Non-spinal criteria: All of: documentation of nonunion of a long-bone fracture; date of fracture; date of recent X-ray; no evidence of fracture healing; if fresh fracture, description of prior treatment and rationale for ultrasonic stimulator; whether other stimulators are in use.

Mapped from CMN Ultrasonic section

Electrical Non-spinal criteria: All of: documentation whether there is nonunion of a long-bone fracture, failed fusion of a joint other than the spine, or congenital pseudoarthrosis; date of fracture or fusion; date of recent X-ray; absence of radiographic evidence of healing.

Mapped from CMN Electrical Non-spinal section

Electrical Spinal criteria: All of: date of spinal fusion; number of fused levels; objective radiological evidence that recent fusion failed to heal (pseudoarthrosis); documentation of prior failed spinal fusion at same site.

Mapped from CMN Electrical Spinal section

The CMN form does not list separate exclusion codes but functions to exclude requests that lack the CMN’s required positive findings. Specifically, absence of documentation required by the device-specific checklist — for example, a missing diagnosis of nonunion, no documentation of failed fusion, no recent X‑ray date, or missing fracture/fusion dates — will be treated as a coverage-limiting caveat and may lead to denial when the checklist items for the selected device are not met. Providers must complete the applicable device section (Ultrasonic non-spinal, Electrical non-spinal, or Electrical spinal) and supply the clinical dates and radiographic information requested on the CMN.

If the completed CMN indicates evidence of fracture healing or otherwise documents absence of the required problem (for example, radiographic evidence of healing, a negative response to the CMN question about nonunion, or documentation that a spinal fusion has healed), the request does not meet the CMN’s medical necessity requirements. The CMN explicitly asks whether there has been evidence of healing for non-spinal fractures and whether a spinal fusion has failed to heal by objective radiological criteria; affirmative documentation of healing or negative responses to nonunion/failed-fusion items functions as a basis for noncoverage.

Provider Actions, Documentation, and Submission Requirements

Documentation Required

Device-specific CMN completion required

Complete the appropriate device-specific CMN (Certificate of Medical Necessity) section for the device being requested (Ultrasonic non-spinal, Electrical non-spinal, or Electrical spinal). The CMN must include device-specific answers (dates of fracture/fusion, recent X-ray date, evidence of healing, and treatment provided for fresh fractures) and a physician signature and date.

Ultrasonic Non-spinal (E0760): complete the ultrasonic device section on the CMN including fracture date, recent X-ray date, evidence of healing, treatment for fresh fractures, and whether other stimulators are in use.
Electrical Non-spinal (20974/20975/E0747): complete the electrical non-spinal device section on the CMN including nonunion/fusion status, congenital pseudoarthrosis, dates, recent X-ray date, and evidence of healing.
Electrical Spinal (E0748/20975): complete the electrical spinal device section on the CMN including date of spinal fusion, number of levels fused, radiological criteria for pseudoarthrosis, prior failed fusion at same site, and physician signature (stamps not acceptable).

Note

Prior or concurrent stimulator use

The CMN asks about any current or prior use of stimulators and prior treatments for fresh fractures. Document whether any other stimulators are currently in use for the same problem and provide details of prior or concurrent stimulator use.

CMN item: "Are any other stimulators currently in use for the same problem?" — must be answered.
For fresh fractures, describe prior treatments provided and rationale for requesting an ultrasonic or electrical stimulator.

Denial Risk

Missing or negative CMN findings

Incomplete, missing, or negative responses on the CMN may result in non-coverage or denial. Ensure all required CMN fields are completed accurately and include a typed office note with pertinent information and a dated physician signature (stamps not acceptable).

Provide a typed office note with pertinent information (dates, imaging, treatment history).
Physician signature and date required on CMN; stamped signatures are not acceptable.
Negative or unanswered CMN items (e.g., missing evidence of healing, missing dates, or unanswered stimulator-use question) may lead to denial.

Background and Clinical Context

Osteogenic stimulators — both ultrasonic and electrical devices — are intended as adjunctive therapy to promote bone healing in situations where healing has not occurred or where fusion has failed. The CMN targets three device categories: Ultrasonic non-spinal (E0760), for long-bone nonunion assessment including fracture date, recent X‑ray, and absence of healing; Electrical non-spinal (20974/20975/E0747), covering nonunion, failed non-spinal joint fusion, or congenital pseudoarthrosis with required dates and radiographic status; and Electrical spinal (E0748/20975), for post‑fusion cases documenting fusion date, number of levels fused, and objective radiologic evidence of pseudoarthrosis or prior failed fusion at the same site. The CMN collects the clinical and imaging details necessary to document the unmet need for stimulation.

Definitions

inv-12: Failed fusion / pseudoarthrosis — definition and CMN documentation

DefinitionA spinal or non-spinal fusion that has not healed, identified by objective radiological criteria and documented on the CMN (pseudoarthrosis/failed fusion).

CMN documentation requiredDate of spinal fusion and number of fused levels must be provided on the CMN.

Radiographic evidenceCMN asks whether recent fusion has failed to heal by objective radiological criteria (Yes/No/Does not apply).

Prior failed fusionCMN requires documentation if the patient had a prior failed spinal fusion at the same site (Yes/No/Does not apply).

inv-13: Nonunion — definition of nonunion of long-bone fracture as captured on the CMN

DefinitionNonunion of a long-bone fracture as assessed on the CMN — lack of radiographic healing documented for a long-bone fracture.

CMN fields requiredCMN requires indication whether there is a nonunion of a long-bone fracture (Yes/No/Does not apply) and the date of fracture.

Radiograph date and healing statusCMN requires the date of a recent X-ray and asks whether there has been evidence of fracture healing (Yes/No).

Fresh fracture contextFor fresh fractures (Ultrasonic section), CMN asks what treatment has been provided and why an ultrasonic stimulator is requested.